- First Name, Last Name and Middle Initial - The provider's first and last name
- Degrees or Credentials - The provider's credentials e.g. MD, DC, PT, etc.
- Tax ID - The provider's Tax ID number or social security number.
- Primary Specialty - The providers specialty (if any)
- License Number - The provider's state licence number.
- Provider ID (UPIN) - The provider's state licence number.
- Cell Phone/Pager - The provider's assigned UPIN number.
- E-mail Address - The provider's e-mail address (if any).
- Medicare Number - The provider’s Medicare number (if any).
- Medicaid Number - The provider's Medicaid number (if any).
- Champus Number - The provider's CHAMPUS number (if any).
- FECA Blk Lung Number - The provider's FECA BLK LUNG number (if any).
